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Kid Safety Alliance

Order Form

Date__________________

Once e-mail verification is received, personal information is deleted from our computers. Child Name: ________________________________________ Nickname: __________________ Address: ______________________________________________________________________ Date of Birth: _______________________ Height: ____________ Hair Color: __________________________ Wear Glasses:

Y

N

Weight: _____________

Eye Color: _______________________

Blood Type: ______________________

Distinguishing Marks: ____________________________________________________________ Known Allergies: ________________________________________________________________ Known Medical Conditions: _______________________________________________________ Daily Medications: ______________________________________________________________ Physician’s Name & Phone #: ______________________________________________________ Dentist’s Name & Phone #: ________________________________________________________ Emergency Contact Name & Phone #: _______________________________________________ Relationship to Child: _____________________________ Additional Emergency Contact Name & Phone #: ______________________________________ Relationship to Child: _____________________________ E-mail for Verification: ___________________________________________________________ If paying by credit card, you may e-mail or fax form to: tamara@kidsafetyalliance.com or (972) 492-8386

Method of Payment: Credit Card Type: Visa

MC

Amex

Discover

Card #:_________________________________

Pricing: Complete Kit: 1 CD, 2 ID Cards, 1 fingerprint card Complete Kit

$20

____________

Additional ID Cards

$1

____________

Additional Fingerprint Cards

$1

____________

Additional CDs

$3

____________

Expiration Date: _________________________ Subtotal

____________

Tax @ 8.25%

____________

Total

____________

Name on Card: __________________________ Signature: ______________________________ Check Payable to: Kid Safety Alliance

Order Form  

For submitting information.